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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850185
Report Date: 10/29/2024
Date Signed: 10/29/2024 10:47:34 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20231211142332
FACILITY NAME:COTTAGES AT THE COLONY OF VALLEY GLEN #4FACILITY NUMBER:
195850185
ADMINISTRATOR:QUINTERO, ELEANORFACILITY TYPE:
740
ADDRESS:6245 MATILIJA AVETELEPHONE:
(818) 855-7035
CITY:VALLEY GLENSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Anna Bernice D Lee, Administrator TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff inappropriately sexually touched a resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver final findings for the above allegation at 10:10 a.m. During today’s visit, the LPA met with Administrator, and explained the reason for the visit.

On 12/12/2023, the Woodland Hills North Adult and Senior Care Regional Office received a complaint regarding a sexual abuse allegation. It was alleged that Staff #1 (S1) inappropriately touched Resident #1 (R1) while under the care of the facility. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Peter Zertuche.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20231211142332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES AT THE COLONY OF VALLEY GLEN #4
FACILITY NUMBER: 195850185
VISIT DATE: 10/29/2024
NARRATIVE
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On 12/12/2023, from 12:45 p.m. to 2:30 p.m., Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to the facility. At 12:55 p.m., LPA Peraldi met with the Administrator and explained the reason for the visit. The LPA informed the Administrator that the complaint was assigned to the CCLD IB Investigator Peter Zertuche. From 12:54 p.m. to 1:30 p.m., the LPA conducted an interview with the Administrator, requested copies of pertinent documents, and along with the Administrator conducted a physical plant tour. The LPA determined further investigation was required prior to issuing a finding.

Investigator Zertuche conducted interviews on 01/31/2024, at approximately 10:30 a.m., with Administrator, Anna Lee, on 01/31/2024, between 11:30 a.m. and 12:30 p.m., with three (3) residents. On 01/31/2024 at 5:30 p.m., Investigator Zertuche conducted a telephonic interview with R1’s son. On 02/06/2024, between 3:30 p.m. and 4:00 p.m., Investigator Zertuche conducted telephonic interview with hospital social worker and hospital nurse. On 02/14/2024, at 10:30 a.m., Investigator Zertuche conducted a telephonic interview with S1. On 02/14/2024, between 11:00 a.m. and 11:30 a.m., Investigator Zertuche conducted a telephonic interview three (3) facility staff. In addition, the investigator requested an incident report from the local police, however police took an injury report and closed their case with no further investigation after speaking to R1 and R1’s son. Investigator Zertuche also obtained and reviewed R1’s medical records.

A review of R1’s Physician Report, dated 6/01/2023, revealed R1 had Dementia, Depression, Hypothyroidism, Insomnia, Seizure Disorder, and Chronic Pain. R1 was non-ambulatory and required assistance with all activities of daily living. R1’s admission agreement was signed and dated on 06/12/2023.

During the Department’s investigation, the interview with R1’s son revealed that R1 had a history of making similar allegations in the past and a history of self-harm, where R1 would scratch R1’s genital area. R1’s son stated that the facility was a great place and did not think the abuse occurred. During the investigation, it was revealed that there were no witnesses to the abuse and per hospital staff, there was no Sexual Assault Response Team (SART) exam, and the cause of the labia tears were unknown. During staff interviews, they denied the allegations of S1 inappropriately touching R1. Interviews with multiple residents all denied that they experienced any type of inappropriate behavior from S1 and instead considered S1 to be a “great person.” Furthermore, interviews with hospital staff indicated that R1’s doctors could not identify the source of the vaginal scratches. None of the residents witnessed S1 behave inappropriately towards R1 or have witnessed any inappropriate behaviors from S1. Interviews with the Administrator and staff denied that any inappropriate behaviors form S1. Continued on LIC 9099-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20231211142332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES AT THE COLONY OF VALLEY GLEN #4
FACILITY NUMBER: 195850185
VISIT DATE: 10/29/2024
NARRATIVE
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The Department’s investigation concluded that although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Sexual Abuse: S1 inappropriately touched R1 while under the care of the facility” is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of this report was issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3